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General NPI Number Information
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NPI Number | 1629187976
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Entity Type | Individual
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Provider Name | SYLVESTER DARREN WALLACE LMSW, ACSW, C-ASWCM
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Gender | Male
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3701 LOOP RD SOCIAL WORK SERVICE 122
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City | TUSCALOOSA
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State | AL
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Zip | 35404-5015
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Country | US
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Telephone | 205-554-2000
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Fax | 205-554-3556
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Provider Business Mailing Address
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Address Line | 7651 HIGHWAY 69 NORTH APT 815
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City | NORTHPORT
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State | AL
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Zip | 35473-7862
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Country | US
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Telephone | 205-339-6098
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | MSW002075
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License Number State | GA
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